Childbirth study finds lesser risk in epidurals

By Carolyn Y. Johnson, Globe Correspondent | February 17, 2005

For years, many women in labor have endured hours of excruciating pain because doctors warned that early use of epidural anesthesia could increase the likelihood of a Caesarean section, a surgical delivery that carries some health risks to the mother. But a new study says that the advice is wrong and that women need not suffer.

Although 60 percent of the approximately 4 million women who give birth in the United States every year receive epidurals, obstetricians disagree about when it is safe to administer, especially for first-time mothers. Under recommendations adopted by the American College of Obstetricians and Gynecologists in 2002, a first-time mother's cervix should be dilated at least 4 centimeters -- nearly halfway to the 10 centimeters needed for a normal delivery -- before an epidural is administered.

Doctors at Northwestern University challenged that guidance in a study published in today's New England Journal of Medicine, in which women given an epidural before they reached the dilation threshold had faster deliveries, better pain relief, and no more C-sections than women who received narcotics. Narcotics are commonly given to women to dull pain early in labor but are not as effective as an epidural, a local anesthetic injected into the membrane around the spinal cord that blocks pain from below the waist.

Efforts to reduce pain in childbirth have long been controversial -- midwives who offered pain relief were burned at the stake in the 15th century. More recently, concerns over the effects of anesthesia on the infant and opposition to the medicalization of childbirth -- which until the last century took place at home -- led to support for "natural" childbirth, which relies on relaxation techniques and other methods to help women deal with pain. But as anesthesia has become safer, the natural-childbirth movement has waned.

"Women basically just get a lot of messages that [labor] is hard to experience . . . and then they may meet some people who can say they do it without [medicine] and it will be better for you, or the opposite. And they feel a certain pressure," said Carol Sakala, director of programs at the New York-based Maternity Center Association, a nonprofit group. She said a recent study showed that an increasing number of women are getting epidurals.

With all the mixed messages, "what happens is really women come into labor unprepared for the pain," said Dr. William Camann, an anesthesiologist at Brigham and Women's Hospital and author of an accompanying editorial in the journal. "This study certainly adds a lot of reassurance to those who want to have epidurals earlier on in labor."

Studies in the early 1990s showed that women who received epidurals early in labor, before their cervix had opened much, had higher rates of C-sections than women who did not. Doctors believed that the epidural might be interfering with the uterus contracting properly. As a result, obstetricians widely began giving women who requested early pain relief narcotics.

But those studies couldn't tease apart cause and effect. The epidural itself could have caused complications that required a C-section. Alternatively, women who requested early epidurals could have been in more pain, and that could have indicated that something was going wrong -- that the baby was too big or turned in the wrong direction, for example.

"To oversimplify things a little bit . . . is it the fact that they have an epidural, or is it the fact that they have a 10-pound baby?" said Dr. Michael Greene, chief of maternal fetal medicine at Massachuestts General Hospital.

In the new study, done between 2000 and 2003, Dr. Cynthia A. Wong and colleagues at Northwestern randomly assigned either an epidural or narcotics to 728 mothers who went into labor naturally and requested pain relief.

Wong said there were no adverse consequences for women or infants given the early epidural. She said she thought the study would probably change the policy of delaying epidurals at Prentice Women's Hospital in Chicago, where the study was conducted. But officials of the American College of Obstetricians and Gynecologists, or ACOG, said they were not likely to change its guidelines based on the study, because the Northwestern doctors combined the epidural with anesthesia injected directly into the spine, an uncommon method.

At some Boston hospitals, there aren't hard and fast rules about when to administer epidurals. At Mass. General, doctors are "liberal" with epidurals, and wouldn't refuse a patient if her cervix were close to 4 centimeters, said Dr. Laura Riley, an obstetrician there. "Judging from what I hear around the country, we are not quite as strict as you have to be," she said. At the Brigham, each patient makes the decision with her doctor, Camann said.

Rebecca Foley gave birth Tuesday at the Brigham to 7-pound, 11-ounce Ryan after six hours of labor. It was a world of difference from her first, 14-hour bout with childbirth. She read. She slept.

This time, the 32-year-old mother received an epidural as soon as she requested it. Two years ago, when she had her first son, Patrick, doctors waited for her cervix to dilate before giving her the shot, and the anesthetic didn't take full effect.

"My sense of humor came back. I would have died if I didn't have this," she said of the epidural.